Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses
Oncologic Outcomes Following Partial Nephrectomy and Percutaneous Ablation for cT1 Renal Masses
复制标题
DOI：
10.1016/j.eururo.2019.04.026
复制
发表时间：
2019-08-01
期刊：
影响因子：
23.4
通讯作者：
Thompson, R. Houston
中科院分区：
文献类型：
--
作者：
Andrews, Jack R.;Atwell, Thomas;Thompson, R. Houston
背景：比较肾部分切除术(PN)和热消融术的长期数据缺乏。目的：更新我们在PN、经皮射频消融术(RFA)和经皮冷冻消融术治疗CT1肾肿块的经验。设计、背景和参与者：共有1798名在梅奥诊所接受治疗的原发cT1N0M0肾肿块患者。干预：经皮消融术和PN。结果测量和统计分析：使用Kaplan-Meier方法估计癌症特异性生存(CS)。结果和局限性：在1422名CTLA患者中，1055名、180名和187名分别接受了PN、RFA和冷冻消融术，中位临床随访期分别为9.4、7.5和6.3年。RFA与PN相比，肾癌局部复发、转移和死亡的危险比(HR)分别为1.49(95%可信区间0.55-404，p=0.4)、1.46(95%可信区间0.41-519，p=0.6)和1.99(95%可信区间0.29-13.56，p=0.5)。冷冻消融与PN相比，相同结果的HR值分别为1.88(95%可信区间0.76~466，p=018)、023(95%可信区间0.03~1.72，p=015)和029(95%可信区间0.01~611，p=OA)。PN组、RFA组和冷冻消融组的5年生存率分别为99%、96%和100%。在376例cT1b患者中，324例和52例分别接受了PN和冷冻消融，中位临床随访期分别为8.7年和6.0年。冷冻消融与PN相比，肾癌局部复发、转移和死亡的HR值分别为122(95%可信区间033~4.48，p=0.8)、0.95(95%可信区间021~438，p>；0.9)和1.94(95%可信区间0.42~8.96，p=OA)。PN组和冷冻消融组的5年CS分别为98%和91%。局限性包括回顾和选择偏差。结论：随着单一机构的成熟随访，经皮消融治疗CT1肾肿瘤似乎具有可接受的结果，适合于有手术禁忌症的患者。对于cT1a患者，PN和消融之间的临床相关差异是不太可能的，治疗选择应该涉及共同的决策。对于cT1b患者，冷冻消融术中死于肾癌更常见，不能排除这一结果的巨大差异。需要进一步的研究来证实冷冻消融术在cT1b环境下的肿瘤学效果。患者总结：在适当的患者分类下，部分肾切除和经皮消融术可以用于治疗CT1肾肿块，尽管还需要更多的随访和进一步的研究。(C)2019年欧洲泌尿外科协会。爱思唯尔出版，版权所有。
Background: Long-term data comparing partial nephrectomy (PN) and thermal ablation are lacking.Objective: To update our experience with PN, percutaneous radiofrequency ablation (RFA), and percutaneous cryoablation for cT1 renal masses.Design, setting, and participants: A total of 1798 patients with primary cT1N0M0 renal masses treated between 2000 and 2011 at Mayo Clinic were identified.Intervention: Percutaneous ablation versus PN.Outcome measurements and statistical analysis: Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Local recurrence, metastases, and death from renal cell carcinoma (RCC) were compared with propensity-score-adjusted Cox models.Results and limitations: Among 1422 cTla patients, 1055, 180, and 187 underwent PN, RFA, and cryoablation with median clinical follow-up of 9.4, 7.5, and 6.3 yr, respectively. Comparisons of RFA with PN resulted in hazard ratios (HRs) of 1.49 (95% confidence interval [CI] 0.55-404,p = 0.4), 1.46 (95% CI 0.41-519,p = 0.6), and 1.99 (95% CI 0.29-13.56,p = 0.5) for local recurrence, metastases, and death from RCC. Comparisons of cryoablation to PN resulted in HRs of 1.88 (95% CI 0.76-466, p = 018), 023 (95% CI 0.03-1.72, p = 015), and 029 (95% CI 0.01-611, p = OA) for these same outcomes. Five-year CSS was 99%, 96%, and 100% for PN, RFA, and cryoablation, respectively. Among 376 cT1b patients, 324 and 52 underwent PN and cryoablation with median clinical follow-up of 8.7 and 6.0 yr, respectively. Comparisons of cryoablation with PN resulted in HRs of 122 (95% CI 033-4.48, p = 0.8), 0.95 (95% CI 021-438, p > 0.9), and 1.94 (95% CI 0.42-8.96, p = OA) for local recurrence, metastases, and death from RCC, respectively. Five-year CSS was 98% and 91% for PN and cryoablation, respectively. Limitations include retrospective review and selection bias.Conclusions: With mature follow-up at a single institution, percutaneous ablation appears to have acceptable results for cT1 renal tumors and is appropriate for patients with a contraindication for surgery. For cT1a patients, clinically relevant differences between PN and ablation are unlikely, and treatment choice should involve shared decision making. For cT1b patients, death from RCC was more common with cryoablation, and large differences in this outcome cannot be ruled out. Further research is needed to confirm the oncologic effectiveness of cryoablation in the cT1b setting.Patient summary: With appropriate patient triage, partial nephrectomy and percutaneous ablation can be used to treat cT1 renal masses, although additional follow-up and further study are still needed. (C) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.